Physiotherapy 104 (2018) 264–276

Systematic review

Effects of orthopaedic manual therapy in knee osteoarthritis:

a systematic review and meta-analysis
Shahnawaz Anwer a,∗ , Ahmad Alghadir a , Hamayun Zafar a ,
Jean-Michel Brismée b
a Rehabilitation Research Chair, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
b Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA

Abstract
Objective This systematic review to aimed to evaluate the effects of orthopaedic manual therapy (OMT) on pain, improving function, and
physical performance in patients with knee osteoarthritis (OA).
Data sources Four databases (PubMed, Web of Science, CENTRAL, and CINAHL) were searched.
Study selection Trials were required to compare OMT alone or OMT in combination with exercise therapy, with exercise therapy alone or
control.
Data extraction Data extraction and risk assessment were done by two independent reviewers. Outcome measures were visual analogue
scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score, WOMAC function score, WOMAC
global score, and stairs ascending-descending time.
Results Eleven randomized controlled trials were included (494 subjects), four of which had a PEDro score of 6 or higher, indicating adequate
quality. The results of the meta-analysis indicated that reduction of VAS score in OMT compared with the control group was statistically
insignificant (SDM: −0.59; 95% CI: −1.54 to −0.36; P = 0.224). The reduction of VAS score in OMT compared with exercise therapy group
was statistically significant (SDM: −0.78; 95% CI: −1.42 to −0.17; P = 0.013). The reduction of WOMAC pain score in OMT compared
with the exercise therapy group was statistically significant (SDM: −0.79; 95% CI: −1.14 to −0.43; P = 0.001). Similarly, the reduction
of WOMAC function score in OMT compared with the exercise therapy group was statistically significant (SDM: −0.85; 95% CI: −1.20
to −0.50; P = 0.001). However, the reduction of WOMAC global score in OMT compared with the exercise therapy group was statistically
insignificant (SDM: −0.23; 95% CI: −0.54 to −0.09; P = 0.164). The reduction of stairs ascending-descending time in OMT compared with
the exercise therapy group was statistically significant (SDM: −0.88; 95% CI: −1.48 to −0.29; P = 0.004).
Conclusions This review indicated OMT compared with exercise therapy alone provides short-term benefits in reducing pain, improving
function, and physical performance in patients with knee OA.

Review registration PROSPERO 2016:CRD42016032799.

© 2018 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Keywords: Knee; Osteoarthritis; Orthopaedic manual therapy; Pain; Function; Exercise

Abbreviations: OA, osteoarthritis; OMT, orthopaedics manual therapy; RCT, randomized controlled trials; VAS, visual analogue scale; WOMAC, Western
Ontario and McMaster Universities Osteoarthritis Index; ROM, range of motion; SDM, standard difference in mean; CI, confidence intervals; GRADE, Grading
of Recommendations Assessment, Development, and Evaluation System; MWM, mobilization with movement.
∗ Corresponding author.

E-mail addresses: sanwer@ksu.edu.sa (S. Anwer), alghadir@ksu.edu.sa (A. Alghadir), hzafar@ksu.edu.sa (H. Zafar), jm.brismee@ttuhsc.edu (J.-M.
Brismée).

https://doi.org/10.1016/j.physio.2018.05.003
0031-9406/© 2018 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

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 S. Anwer et al. / Physiotherapy 104 (2018) 264–276
Introduction
The prevalence of knee osteoarthritis (OA) is gradually
increasing worldwide and is the commonest cause of disabil-
ity in older adults [1,2]. Approximately 9% of people aged
60 years and older are diagnosed with symptomatic knee OA
in the United States [3]. Due to its chronic nature and high
treatment costs, knee OA becomes a significant burden to
society [4]. The major symptoms of knee OA include pain,
stiffness in the affected joint and functional disability, which
can affect the quality of life [5].
Orthopaedic manual therapy (OMT) is defined as “any
hands-on therapy given by the physical therapist. Intervention
may include moving joints in various and specific directions
and at various speeds to regain movement (joint mobiliza-
tion and manipulation), stretching, passive range of motion
(ROM) exercise of the affected body part, or having the
patient move the body part against the therapist’s resistance
to improve muscle activation and timing. Selected certain soft
tissue techniques may also be used to improve the mobility
and function of tissue and muscles [6].” Abbott et al. [7]
reported long term beneficial effects (up to 1 year) of OMT
compared with usual care in patients with hip or knee OA.
However, the authors did not show any additional benefits
of OMT in combination with exercise therapy in patients
with hip or knee OA [7]. Similarly, Kappetijn et al. [8]
reported a beneficial effect of passive mobilisation in com-
bination with exercise therapy in reducing pain, functional
limitation and improving extension ROM of knee joint in
patients with knee OA. In addition, Jansen et al. [9] reported
a moderate effect size on pain reduction following exercise
therapy plus manual mobilisation compared to small effect
sizes for strength training or exercise therapy alone in patients
with knee OA. Moreover, Pinto et al. [10] reported that the
exercise therapy and OMT in isolation was more cost effec-
tive compared to usual care in patients with hip or knee
OA.
Over the last 10 years, several studies assessing the effects
of OMT published that seems to indicate that OMT is an
effective treatment approach for musculoskeletal disorders
[11–18]. However, there is inconclusive evidence on the
overall effects of OMT treatment [19]. Previous studies
have demonstrated promising effects of OMT in reducing
pain and improving physical function in patients with knee
OA [7,8,10,20,21], but isolated effectiveness of OMT has
not been well-established [22,23]. In addition, only two
systematic reviews and meta-analyses have been published
indicating effectiveness of OMT and exercise for managing
pain and functional limitations in individuals with knee OA
[9,23]. However, French et al. [23] study included only 4 trials
out of which 3 had a high risk of bias, whereas, Jansen et al.
[9] study did not assess risk of bias in their included trials.
Therefore, this systematic review and meta-analysis aimed
to evaluate the effects of OMT on pain, functional disability,
ROM, and physical performance in patients with knee OA.
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265
Methods
The current systematic review used the Preferred Report-
ing Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines for conducting search and reporting
the trials [24]. This systematic review was prospec-
tively registered in PROSPERO (CRD42016032799) and
available at http://www.crd.york.ac.uk/PROSPERO/display
record.asp?ID=CRD42016032799.
Database and search strategies
Four databases (PubMed, Web of Science, CENTRAL,
and CINAHL) were searched by two independent reviewers
from the time of their inception to February 6, 2017. The lan-
guage of the articles was restricted to English. The literature
search was conducted using the major key words knee OA
and OMT; which were adapted for each database as required
(as shown in supplementary Table A in the online version
at DOI:10.1016/j.physio.2018.05.003). Additional potential
articles were searched manually from the reference lists of
identified articles.
Inclusion and exclusion criteria for selection of studies
The current systematic review included all the published
articles that qualified the following PICOS criteria:
Participants: adults over 30 years of age diagnosed with
knee OA (unilateral or bilateral) as per criteria given by the
American College of Rheumatology [25,26] or had a radio-
graphic or symptomatic knee OA diagnosed by a physician.
Interventions: OMT alone or OMT in combination with
exercise therapy
Comparators: exercise therapy alone or electrotherapy
or control
Outcomes: pain, functional disability, ROM, and physical
performance
Study design: randomised controlled trials (RCTs)
Studies were excluded if they were not published in
the English. In addition, due to risk of high potential bias,
non-randomised and cross-sectional studies, case reports and
case series were also excluded. Furthermore, Studies that did
not include OMT in their interventions were excluded.
Study selection
Only randomised controlled trials (RCTs) were included
in this meta-analysis. The outcome measures of interest
were pain, functional disability, ROM, and physical per-
formance in individuals with knee OA. Pain, functional
disability, ROM, and physical performance were measured
using a visual analog scale (VAS), the Western Ontario
and McMaster Universities Osteoarthritis Index (WOMAC)
scale, goniometry, and stairs ascending-descending time,
respectively.
266 S. Anwer et al. / Physiotherapy 104 (2018) 264–276
Data extraction
Two independent reviewers screened titles and abstract
of searched articles to exclude apparently irrelevant articles.
Full texts of the possible articles were reviewed to identify
eligible trials. Data were extracted from the included studies
according to the following parameters: author/year, subjects,
design, intervention, OMT component, frequency, duration,
outcomes, and conclusions. Both the reviewers discussed
and resolved any disagreements by consensus between both
reviewers.
Quality assessment
Two independent reviewers assessed the study quality
using the 11 item PEDro scale [27–29]. A PEDro score of
6 or greater was considered as an adequate quality study
[28,30–32]. In addition, the Cochrane Collaboration tool was
used to determine risk of bias in the included trials. Risk
of bias was indicated as low, unclear, or high in each sec-
tion [33]. Both the reviewers discussed and resolved any
disagreements. Furthermore, the Grading of Recommen-
dations Assessment, Development, and Evaluation System
(GRADE) was used to determine the quality of evidence for
each meta-analysis [34]. This method comprises downgrad-
ing evidence from high- to moderate- to low- and to very
low-quality using various factors. If most of the included
trials (more than 50%) in the meta-analysis had a PEDro
score <6 or had high percentage of statistical heterogeneity
between the trials (I2 > 25%) [35], or if the trials had large
confidence intervals indicating a small number of subjects
in the trials, then the evidence was downgraded, for exam-
ple, from high- to moderate-quality. If there was a serious
methodological flaw in the included trials such as all trials
in the meta-analysis displaying low PEDro scores (<6) with
no blinding and allocation concealment, the evidence was
double downgraded (e.g. from high- to low-quality).
Measures of treatment effect
A meta-analysis was conducted using the Comprehensive
Meta-Analysis software [36], if at least two trials of compa-
rable OMT intervention and outcomes existed. The standard
difference in mean (SDM) with 95% confidence intervals
(CI) for all outcomes was calculated. Cohen’s categories were
used to judge the overall effect sizes as follows: effect sizes
of 0.2 to 0.5 indicated a small effect, 0.5 to 0.8 a moderate
effect, and >0.8 a large effect [37].
Assessment of heterogeneity
Statistical heterogeneity among the trials was tested using
the Cochran’s Q statistic and Higgins’ I2 statistic. A value of
I2 > 25%, I2 > 50%, and I2 > 75% were indicated as moder-
ate, substantial, and considerable heterogeneity, respectively
[38]. A random-effects meta-analysis was conducted if I2
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value was >25%. Alternatively, a fixed-effects meta-analysis
was conducted [39].
Results
Study selection and characteristics
A total of 428 articles were screened for title search after
excluding the duplicates (n = 214) (Fig. 1). Thirty full-text
papers were reviewed for eligibility [7,8,10,20,21,40–64] of
which, 19 full-text papers were excluded due to lack of con-
trol group, presence of multimodal treatment or the OMT
was not defined [8,10,20,21,40–54]. Eleven trials involving
494 subjects were included in the qualitative and quantitative
analyses [7,55–64]. Table 1 details the characteristics, inter-
ventions, OMT component, frequency, duration, outcomes,
PEDro score and conclusions of the included trials.
Trials originated from South Africa [55], New Zealand
[7], Malaysia [56], Pakistan [57,63], Korea [58,62], Spain
[59], Egypt [60], Australia [61], and the United States
[55,64]. Subjects were recruited from outpatient departments
[7,55–58,60], elderly/adult care center [59], orthopedic hos-
pital [62], rehabilitation center [63], healthcare center [64],
or through advertisements in print media [61]. Subjects’
age ranged from 35 to 91 years, and the male to female
ratio was 37.6/62.4. Among OMT intervention, Maitland
joint mobilisation was the most common utilized techniques
[7,55–58,63], followed by therapeutic massage [59,64],
mobilisation with movement (MWM) using Mulligan tech-
nique [60,62], and myofascial mobilisation with impulse
thrust [61]. OMT intervention duration ranged from 2 to
16 weeks, of which half of the included trials reported a
4-week intervention duration. The frequency of the OMT
intervention was 2 to 3/week.
The majority of the included trials used the
WOMAC scale to measure pain and functional dis-
ability [7,55,57,59,60,62,64]. In addition, most of the
included trials used the VAS to measure pain intensity
[56,59–64]. Two studies used stairs ascending-descending
time to measure physical performance of the subjects with
knee OA [56,58]. Three trials had a PEDro score of 8, one
trial of 6, three trials of 5, and four trials of 4.
Risk of bias in included studies
Risk of bias graph and risk of bias summary are measured
as a percentage as shown in the supplementary Figs. A and B
in the online version at DOI:10.1016/j.physio.2018.05.003,
respectively. As per the Cochrane Collaboration tool, three
trials received the maximum quality score [7,55,59]. All
the 11 included studies had a high risk of bias. Five
included trials provided adequate random sequence genera-
tion [7,55,59,61,64]. Lack of double blinding was present in
most of the included trials. Blinding of outcome assessment
was present in the four included trials [7,55,56,59]. Most of
 S. Anwer et al. / Physiotherapy 104 (2018) 264–276 267

Fig. 1. Study selection process and results of the literature search.

the included trials presented low risk of bias for incomplete
outcome data.
Effect of interventions
The effect of OMT intervention in subjects with knee
OA and quality of evidence are shown in Figs. 2–6 and
Table 2, respectively. The included studies were grouped as
OMT vs control and OMT vs exercise therapy. Results of the
meta-analysis indicated that reduction of VAS score in OMT
compared with control group was statistically insignificant
(SDM: -0.59; 95% CI: -1.54 to -0.36; P = 0.224) [Quality of
evidence, Low]. The reduction of VAS score in OMT com-
pared with exercise therapy group was statistically significant
(SDM: -0.78; 95% CI: -1.42 to -0.17; P = 0.013) [Quality of
evidence, Low]. The reduction of WOMAC pain score in
OMT compared with exercise therapy group was statistically
significant (SDM: -0.79; 95% CI: -1.14 to -0.43; P = 0.001)
[Quality of evidence, Moderate]. Similarly, the reduction of
WOMAC function score in OMT compared with exercise

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 268
Table 1
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Characteristics and PEDro scores of the selected studies.

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Study Subjects Mean age, years Group OMT component Frequency/duration Outcomes/timings PEDro Conclusions
(male/female, %) score
Dwyer 2015 [54] Participants with Group 1: 63.5 (27/73) 1: OMT (n = 26) Maitland joint 2/week, 4 weeks WOMAC-pain score 8 Significant changes in
mild-moderate knee Group 2: 60.9 (42/58) 2: Exercise therapy mobilization (grades 1 WOMAC-function the pain and function
OA based on clinical (n = 26) to 4) and joint score scores were seen in
and radiographic manipulation (grade Timings: 4 weeks both the groups. No
criteria of ACR and 5; high-velocity, between groups
the low-amplitude, differences in any
Kellgren–Lawrence thrust-type outcomes were noted.
grade for knee OA (0 manipulation) of the
to 3) affected kinematic

S. Anwer et al. / Physiotherapy 104 (2018) 264–276

chain (knee, hip, foot,
and spine)
Abbott 2013 [7] Participants with knee Group 1: 67.3 (48/52) 1: OMT and usual Knee flexion, 9 sessions over 16 WOMAC-Global 8 Manual physiotherapy
OA based on clinical care (n = 54) antero-posterior glide weeks score program leads to
and radiographic of tibia on femur, significantly better
criteria of ACR postero-anterior glide improvements in the
of tibia on femur, knee OA symptoms
patellar gliding force compared to the usual
(all non-thrust) care.
Group 2: 66.1 (51/49) 2: Usual care (51) Manual stretching Follow-up: 1-year Timings: 1-year
Soft tissue
manipulation
Nor Azlin 2011 [56] Clinical and Group 1: 63.1 (14/86) 1: OMT and exercise Maitland joint 2/week, 4 weeks VAS (pain during stair 5 Addition of Maitland
radiographic therapy (n = 7) mobilization climbing) joint mobilization
diagnosis of sub-acute Group 2: 59.7 (17/83) 2: Exercise therapy including Stairs technique to
or chronic knee OA (n = 6) antero-posterior (AP) ascending-descending traditional
with pain at least in glide of tibia on time physiotherapy causes
one knee femur, and patella Timings: 4 weeks decreased pain but no
glides in all directions. improvement in stairs
ascending-descending
time.
Ali 2014 [57] Participants with Group 1:? 1: OMT and exercise Maitland joint 3/week, 4 weeks WOMAC-pain score 4 Maitland joint
mild-moderate knee therapy (n = 25) mobilization with mobilization
OA based on clinical Group 2:? 2: Electrotherapy and distraction on WOMAC-function technique leads to
and radiographic exercise therapy tibiofemoral joint and score significantly better
criteria of ACR (n = 25) patella-femoral joint. improvements in pain
Total subjects: 50.5 Timings: 4 weeks and physical function.
(48/52)
 Ko 2009 [58] Elderly women with Group 1: 63.7 (0/100) 1: OMT and exercise Maitland joint 3/weeks, 8 weeks Stairs 4 Addition of Maitland
knee OA therapy (n = 18) mobilization ascending-descending joint mobilization
including time technique to resistive
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Group 2: 65.3 (0/100) 2: Exercise therapy antero-posterior (AP) Timings: 8 weeks exercise leads to
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(n = 17) glide of tibia on significantly better

femur, and patella improvements in the
distal glides. functional
performance than
resistive exercise
alone.
Godoy 2014 [59] Clinical and Group 1: 85† (0/100) 1: OMT and exercise Massage-therapy 2/week, 6 weeks WOMAC-Global 8 Addition of massage
radiographic therapy (n = 9) including pressure, score therapy to exercise
diagnosis of knee OA. Group 2: 84† (0/100) 2: Exercise therapy muscle stripping and Follow-up:3-month VAS therapy program does
(n = 9) kneading to not report any
quadriceps and Timings: 3 months additional benefits

S. Anwer et al. / Physiotherapy 104 (2018) 264–276

hamstring muscles compared to exercise
therapy alone.
Razek 2014 [60] Clinical and Group 1: 44.5 (33/67) 1: OMT (n = 15) Mobilization with 3/week, 4 weeks VAS 6 MWM technique
radiographic Group 2: 50.1 (27/73) 2: Exercise therapy movement (MWM) WOMAC-Global showed better
diagnosis of knee OA. (n = 15) using Mulligan score improvements in pain
techniques — Medial ROM and range of motion,
glide MWM, Lateral Timings: 4 weeks but no difference in
glide MWM; Dorsal the functional
glide with active knee disability.
flexion and Rotation
MWM.
Pollard 2008 [61] Participants with knee Group 1:56.5 (69/31) 1: OMT (n = 26) Macquarie Injury 3/week, 2 weeks VAS (current pain) 5 A short-term OMT
OA as per Forman Group 2: 54.6 (65/35) 2: Control (no Management Group Timings: 4 weeks knee protocol leads to
et al. (1983) treatment) (n = 17) Knee Protocol a significantly better
(MIMG) including a reduction in knee
non-invasive pain.
myofascial
mobilisation
procedure and an
impulse thrust
procedure
Nam 2013 [62] Participants with Group 1: 66.1 (27/73) 1: OMT and exercise MWM using Mulligan 3/week, 6 weeks VAS 4 MWM technique
radiographic therapy (n = 15) techniques showed better
diagnosis of knee OA Group 2: 64.2 (27/73) 2: Exercise therapy WOMAC-pain score improvements in pain
(n = 15) and physical function
WOMAC-function compared to exercise
score therapy alone.
Timings: 6 weeks

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Table 1 (Continued)
Study Subjects Mean age, years Group OMT component Frequency/duration Outcomes/timings PEDro Conclusions

S. Anwer et al. / Physiotherapy 104 (2018) 264–276

(male/female, %) score
Ahmad 2016 [63] Participants with knee Group 1: 53.3 (?/?) 1: OMT (n = 25) Maitland joint 3/week, 8 weeks VAS 4 Maitland joint
OA Group 2: 49.7 (?/?) 2: Exercise therapy mobilization Timings: 8 weeks mobilization
(n = 25) including technique leads to
antero-posterior (AP) significantly better
glide of tibia on improvements in knee
femur. pain than exercise
therapy.
Perlman 2006 [64] Participants with knee Group 1: 70.4 (21/79) 1: OMT (n = 34) Therapeutic massage 2/week, 1 to 4 weeks VAS 5 Therapeutic massage
OA based on clinical Group 2: 66.2 (23/77) 2: Control (no technique including 1/week, 5 to 8 weeks WOMAC-pain score seems to be effective
and radiographic treatment) (n = 34) petrissage, effleurage, in the management of
criteria of ACR and tapotement. Follow-up: 16 weeks WOMAC-function knee OA.
score
ROM
Timings: 16 weeks
†: Median value; ?: not reported; ACR; American College of Rheumatology; VAS: visual analogue scale; OA: osteoarthritis; ROM: range of motion; WOMAC: Western Ontario and McMaster Universities
Osteoarthritis Index; OMT: orthopaedic manual therapy.
 S. Anwer et al. / Physiotherapy 104 (2018) 264–276 271

Fig. 2. Standard difference in mean (Std diff in means) and 95% confidence intervals of Visual analogue scale score (0 to 10 cm) comparing OMT with exercise
therapy in patients with knee OA.

Fig. 3. Standard difference in mean (Std diff in means) and 95% confidence intervals of WOMAC-pain score comparing OMT with exercise therapy in patients
with knee OA.

Fig. 4. Standard difference in mean (Std diff in means) and 95% confidence intervals of WOMAC-function score comparing OMT with exercise therapy in
patients with knee OA.

therapy group was statistically significant (SDM: -0.85; 95%
CI: -1.20 to -0.50; P = 0.001) [Quality of evidence, Mod-
erate]. However, the reduction of WOMAC global score in
OMT compared with exercise therapy group was statisti-
cally insignificant (SDM: -0.23; 95% CI: -0.54 to -0.09;
P = 0.164) [Quality of evidence, High]. The reduction of
stairs ascending-descending time in OMT compared with
exercise therapy group was statistically significant (SDM: -
0.88; 95% CI: -1.48 to -0.29; P = 0.004) [Quality of evidence,
Low]. Heterogeneity in the included trials were calculated for
VAS (I2 = 83%, OMT vs Control), VAS (I2 = 67%, OMT vs
Exercise therapy), WOMAC-pain score (I2 = 0%, OMT vs
Exercise therapy), WOMAC-function score (I2 = 0%, OMT
vs Exercise therapy), WOMAC-Global score (I2 = 0%, OMT
vs Exercise therapy), and stairs ascending-descending time
(I2 = 0%, OMT vs Exercise therapy). Only VAS pain was ana-

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272 S. Anwer et al. / Physiotherapy 104 (2018) 264–276

Fig. 5. Standard difference in mean (Std diff in means) and 95% confidence intervals of WOMAC-Global score comparing OMT with exercise therapy in
patients with knee OA.

Fig. 6. Standard difference in mean (Std diff in means) and 95% confidence intervals of Stairs ascending-descending time (second) comparing OMT with
exercise therapy in patients with knee OA.

Table 2
Meta-analyses of the effects of OMT in subjects with knee OA.
No. of Ratio of No. of SMD [95% CI] I2 Quality of
studies studies subjects evidence
(PEDro <6) (GRADE)
VAS (OMT VS Control) 2 100% 111 −0.59 [−1.054, −0.36] 83% Low†
VAS (OMT vs Exercise therapy) 5 60% 141 −0.80 [−1.42, −0.17] 67% Low†
WOMAC-pain score (OMT vs Exercise therapy) 3 67% 132 −0.79 [−1.14, −0.43] 0% Moderate‡
WOMAC-function score (OMT vs Exercise therapy) 3 67% 132 −0.85 [−1.20, −0.50] 0% Moderate‡
WOMAC-Global score (OMT vs Exercise therapy) 3 0% 153 −0.23 [−0.54, −0.09] 0% High
Stairs ascending-descending time (OMT vs Exercise therapy) 2 100% 48 −0.88 [−1.48, −0.29] 0% Low¶
GRADE: GRADE working group grades of evidence; VAS: visual analogue scale; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index;
OMT: orthopeadic manual therapy.
† More than 50% of the studies in the meta-analysis had a PEDro score <6 and statistical heterogeneity (I2 > 25%) results double downgrade; ‡ more than 50%
of the studies in the meta-analysis had a PEDro score <6 results downgrade; ¶ all trials in the meta-analysis had a PEDro score <6, large confidence interval,
and with no allocation concealment and blinding results double downgrade.

lysed using a random effects meta-analysis, while all other
analyses used fixed effects meta-analysis.
Discussion
The present meta-analysis of the current literature indi-
cated that OMT interventions with exercise therapy compared
with exercise therapy alone provide short term benefits in
reducing pain, improving function, and stairs ascending-
descending time in people with knee OA. Low to moderate
quality of evidence suggested that the supplementation of
OMT with exercise therapy could reduce pain, improve phys-
ical function, and stairs ascending-descending time in people
with knee OA. Similar to previous review, the meta-analysis
of current review indicated a moderate effect size of pain
reduction in OMT intervention compared with exercise ther-
apy or control group [65]. The meta-analysis of current review
indicated a large effect size of improved function in OMT
intervention compared with exercise therapy. In contrast, pre-
vious review indicated a small effect of improved function in
OMT intervention compared with control group [65]. How-

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 S. Anwer et al. / Physiotherapy 104 (2018) 264–276
ever, in the previous review, control group received various
alternative interventions [65].
OMT is effective in improving pain and physical perfor-
mance by addressing impaired joint kinematics, which can
be due to loss of periarticular flexibility, capsular contracture,
and increased intracapsular pressure in subjects with knee
OA [66]. Several mechanisms have been proposed explaining
pain reduction following OMT [67–69]. Joint mobilisa-
tion reduces pain by stimulating neurophysiological effects
through activating type II mechanoreceptors and inhibiting
type IV nociceptors [68]. In addition, joint mobilisation
enhances Golgi tendon organ activity and causes muscle
relaxation via reflex inhibition [67]. Furthermore, mus-
cle inhibition following joint mobilisation causes reduced
concentric muscle contraction and muscle tension in the peri-
articular tissue, thereby reducing pain [69]. Moreover, joint
mobilisation enhances pain modulation and somatosensory
acuity in patients with painful knee OA [51]. However, more
research is warranted to expand our understanding of the
mechanisms of action of OMT in subjects with symptomatic
knee OA.
Previous researches recommended the use of manual ther-
apy to achieve changes in the neuromuscular system [19]. It
was suggested that manual therapy gives a mechanical stim-
ulus to change the neuromuscular system via various reflexes
and neurophysiological mechanisms [70]. The changes in the
neuromuscular system help to correct maladaptive movement
and to improve functional disability [19]. A recent system-
atic review indicated that manual therapy was an effective
alternative and complimentary treatment approach for the
management of knee OA [65]. A clinical guideline given
by the National Institute for Health and Care Excellence
(NICE) in 2008 has included manipulation and stretching
as an adjunct to core treatment for the management of knee
OA [71].
In previous systematic reviews and meta-analyses, Jansen
et al. [9] indicated that manual mobilisation supplementation
with exercise therapy achieved greater pain relief in subjects
with knee OA, while French et al. [23] indicated that OMT in
the form of therapeutic massage was effective compared to no
treatment in patients with knee OA. In addition, a previous
study reported the beneficial effect of passive mobilisation
in combination with exercise therapy in reducing pain and
improving extension ROM and function in patients with knee
OA [8].
In the present review, most of the included trials used
Maitland joint mobilisation techniques as a component of
OMT [7,56–58,63]. Most of the manual mobilisation tech-
niques used by physiotherapists in treating knee pain were
components of Maitland mobilisation techniques [72]. In a
non-randomised trial, Moss et al. [73] reported a significant
pain reduction and improved function following application
of accessory joint mobilisations in patients with mild to mod-
erate knee OA.
A few of the trials in this systematic review also used
therapeutic massage [59,64], mobilisation with movement
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273
(MWM) following Mulligan concepts [60,62], and myofas-
cial mobilisation with impulse thrusts [61]. In a prospective
case series, Takasaki et al. [74] reported immediate pain
reduction and improved physical function following MWM
in patients with knee OA. Although the mechanism of pain
reduction by MWM is not well understood, neurophysiolog-
ical processes such as descending pain inhibitory pathways
[75,76] and central pain-processing mechanisms [75,77],
and biomechanical mechanisms such as correcting positional
fault, thereby reducing pain [78,79] have been suggested.
Strengths and limitations
The major strength of this review was inclusion of trials,
which had a high PEDro score. In addition, heterogeneity
in the included trials was very low for all the outcomes,
except for VAS. The present review provides extensive qual-
itative and quantitative analysis of the literature regarding
the effects of OMT in patients with knee OA. The this sys-
tematic review had some limitations by having only short
term effects of OMT in patients with knee OA and only three
trials with long term follow-up ranging from 3-month to 1-
year [7,59,64]. Abbott et al. [7] reported a significantly better
effect of OMT on OA symptoms than usual care after one-
year follow-up. In addition, Perlman et al. [63] reported a
significant effect of therapeutic massage, a form of OMT
compared with no treatment in the management of knee OA.
In contrast, Godoy et al. [59] did not report any additional
benefits of therapeutic massage compared to exercise ther-
apy in knee OA. However, due to heterogeneity in the design,
participants and outcome, long term effects could not be eval-
uated. Further studies assessing the long term effects of OMT
on these outcomes may have significant implications for the
management of knee OA. In addition, a direct comparison
on the effects among different OMT such as Maitland joint
mobilisation, Kaltenborn mobilisation, and MWM could not
be made. Furthermore, chronicity of the OA was not given
in the included trials; therefore, it was not clear if manual
therapy was more effective in acute or chronic conditions.
Another important limitation could be the lack of information
about the affected knee compartment such as tibiofemoral or
patellofemoral in the included studies. As we know, some of
the OMT treatments involved the patellofemoral joint specif-
ically. Moreover, due to lack of published trials, some of the
important outcomes such as muscle strength and gait param-
eters were not studied in the present review. Further studies
assessing the effects of OMT on muscle strength and gait
parameters are warranted.
Conclusions
This systematic review indicated OMT with and with-
out exercise therapy provides short term benefits in reducing
pain, improving function, ROM and physical performance
in patients with knee OA. However, more randomised con-
274 S. Anwer et al. / Physiotherapy 104 (2018) 264–276
Key messages
• This systematic review evaluated eleven trials involv-
ing 494 subjects to examine the effects of orthopaedic
manual therapy (OMT) on pain, improving func-
tion, and physical performance in patients with knee
osteoarthritis (OA).
• This systematic review indicated OMT compared
with exercise therapy alone provides short-term bene-
fits in reducing pain, improving function, and physical
performance in patients with knee OA.
• However, more randomised controlled studies are
warranted to improve evidence on the effect of iso-
lated OMT intervention in patients with knee OA.
• Furthermore, quality trials investigating the long-
term effects of OMT intervention in subjects with
knee OA are needed.
trolled studies are warranted to improve evidence on the effect
of isolated OMT intervention in patients with knee OA. Fur-
thermore, quality trials investigating the long term effects of
OMT intervention in subjects with knee OA are needed.
Acknowledgments
The authors are grateful to the Deanship of Scientific
Research, King Saud University for funding through Vice
Deanship of Scientific Research Chairs.
Conflict of interest: None declared.
References
[1] Paradowski PT, Lohmander LS, Englund M. Osteoarthritis of the
knee after meniscal resection: long term radiographic evaluation
of disease progression. Osteoarthritis Cartilage 2016;24(5):794–800,
http://dx.doi.org/10.1016/j.joca.2015.12.002. Epub 2015 Dec 17.
[2] McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Beren-
baum F, Bierma-Zeinstra SM, et al. OARSI guidelines for the
non-surgical management of knee osteoarthritis. Osteoarthritis Carti-
lage 2014;22(3):363–88, http://dx.doi.org/10.1016/j.joca.2014.01.003.
[3] Losina E, Weinstein AM, Reichmann WM, Burbine SA, Solomon
DH, Daigle ME, et al. Lifetime risk and age at diagnosis of symp-
tomatic knee osteoarthritis in the US. Arthritis Care Res (Hoboken)
2013;65(5):703–11, http://dx.doi.org/10.1002/acr.21898.
[4] Hermans J, Koopmanschap MA, Bierma-Zeinstra SM, van Linge JH,
Verhaar JA, Reijman M, et al. Productivity costs and medical costs
among working patients with knee osteoarthritis. Arthritis Care Res
(Hoboken) 2012;64(6):853–61, http://dx.doi.org/10.1002/acr.21617.
[5] Oiestad BE, White DK, Booton R, Niu J, Zhang Y, Torner J,
et al. Longitudinal course of physical function in people with symp-
tomatic knee osteoarthritis: data from the Multicenter Osteoarthritis
Study and the Osteoarthritis Initiative. Arthritis Care Res (Hoboken)
2016;68(3):325–31, http://dx.doi.org/10.1002/acr.22674.
[6] Mintken PE, DeRosa C, Little T, Smith B, American Academy of
Orthopaedic Manual Physical Therapists. AAOMPT clinical guide-
lines: a model for standardizing manipulation terminology in physical
Downloaded for Anonymous User (n/a) at A T Still University from ClinicalKey.com by Elsevier on May 21, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
therapy practice. J Orthop Sports Phys Ther 2008;38(3):A1–6,
http://dx.doi.org/10.1179/106698108790818567.
[7] Abbott JH, Robertson MC, Chapple C, Pinto D, Wright AA, Leon de
la Barra S, et al. Manual therapy, exercise therapy, or both, in addi-
tion to usual care, for osteoarthritis of the hip or knee: a randomised
controlled trial. 1: clinical effectiveness. Osteoarthritis Cartilage
2013;21(4):525–34, http://dx.doi.org/10.1016/j.joca.2012.12.014.
[8] Kappetijn O, van Trijffel E, Lucas C. Efficacy of passive exten-
sion mobilization in addition to exercise in the osteoarthritic
knee: an observational parallel-group study. Knee 2014;21(3):703–9,
http://dx.doi.org/10.1016/j.knee.2014.03.003.
[9] Jansen MJ, Viechtbauer W, Lenssen AF, Hendriks EJ, de
Bie RA. Strength training alone, exercise therapy alone,
and exercise therapy with passive manual mobilisation each
reduce pain and disability in people with knee osteoarthri-
tis: a systematic review. J Physiother 2011;57(1):11–20,
http://dx.doi.org/10.1016/S1836-9553(11)70002-9.
[10] Pinto D, Robertson MC, Abbott JH, Hansen P, Campbell AJ, Team
MOAT. Manual therapy, exercise therapy, or both, in addition to
usual care, for osteoarthritis of the hip or knee. 2: economic evalua-
tion alongside a randomised controlled trial. Osteoarthritis Cartilage
2013;21(10):1504–13, http://dx.doi.org/10.1016/j.joca.2013.06.014.
[11] Bautmans I, Van Arken J, Van Mackelenberg M, Mets T. Reha-
bilitation using manual mobilization for thoracic kyphosis in
elderly postmenopausal patients with osteoporosis. J Rehabil Med
2010;42(2):129–35, http://dx.doi.org/10.2340/16501977-0486.
[12] Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore
JH, et al. The short-term effects of thoracic spine thrust manipu-
lation on patients with shoulder impingement syndrome. Man Ther
2009;14(4):375–80, http://dx.doi.org/10.1016/j.math.2008.05.005.
[13] Camarinos J, Marinko L. Effectiveness of manual physical therapy for
painful shoulder conditions: a systematic review. J Man Manip Ther
2009;17(4):206–15, http://dx.doi.org/10.1179/106698109791352076.
[14] Dunning JR, Butts R, Mourad F, Young I, Fernandez-de-Las Peñas C,
Hagins M, et al. Upper cervical and upper thoracic manipulation versus
mobilization and exercise in patients with cervicogenic headache:
A multi-center randomized clinical trial. BMC Musculoskelet Dis
2016;17(1):64, http://dx.doi.org/10.1186/s12891-016-0912-3.
[15] Gonzalez-Iglesias J, Fernandez-de-las-Penas C, Cleland JA,
Alburquerque-Sendín F, Palomeque-del-Cerro L, Méndez-Sánchez
R. Inclusion of thoracic spine thrust manipulation into an elec-
trotherapy/thermal program for the management of patients with
acute mechanical neck pain: a randomized clinical trial. Man Ther
2009;14(3):306–13, http://dx.doi.org/10.1016/j.math.2008.04.006.
[16] Gonzalez-Iglesias J, Fernandez-de-las-Penas C, Cleland JA,
Gutiérrez-Vega Mdel R. Thoracic spine manipulation for
the management of patients with neck pain: a randomized
clinical trial. J Orthop Sports Phys Ther 2009;39(1):20–7,
http://dx.doi.org/10.2519/jospt.2009.2914.
[17] Leaver AM, Maher CG, Herbert RD, Latimer J, McAuley JH, Jull
G, et al. A randomized controlled trial comparing manipulation with
mobilization for recent onset neck pain. Arch Phys Med Rehabil
2010;91(9):1313–8, http://dx.doi.org/10.1016/j.apmr.2010.06.006.
[18] Masaracchio M, Cleland JA, Hellman M, Hagins M. Short-term com-
bined effects of thoracic spine thrust manipulation and cervical spine
nonthrust manipulation in individuals with mechanical neck pain: a ran-
domized clinical trial. J Orthop Sports Phys Ther 2013;43(3):118–27,
http://dx.doi.org/10.2519/jospt.2013.4221.
[19] Collins CK, Masaracchio M, Brismée JM. The
future of orthopedic manual therapy: what are we
missing? J Man Manip Ther 2017;25(4):169–71,
http://dx.doi.org/10.1080/10669817.2017.1358249.
[20] Deyle GD, Allison SC, Matekel RL, Ryder MG, Stang JM, Gohdes
DD, et al. Physical therapy treatment effectiveness for osteoarthritis of
the knee: a randomized comparisonof supervised clinical exercise and
 S. Anwer et al. / Physiotherapy 104 (2018) 264–276
manual therapy procedures versus a home exercise program. Phys Ther
2005;85(12):1301–17.
[21] Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Alli-
son SC. Effectiveness of manual physical therapy and exercise in
osteoarthritis of the knee. A randomised, controlled trial. Ann Intern
Med 2000;132(3):173–81.
[22] Ottawa panel evidence-based clinical practice guidelines for therapeutic
exercises and manual therapy in the management of osteoarthritis. Phys
Ther 2005;85(9):907–71.
[23] French HP, Brennan A, White B, Cusack T. Manual therapy for
osteoarthritis of the hip or knee — a systematic review. Man Ther
2011;16(2):109–17, http://dx.doi.org/10.1016/j.math.2010.10.011.
[24] Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group.
Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. BMJ 2009;339:b2535,
http://dx.doi.org/10.1136/bmj.b2535.
[25] Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K,
et al. Development of criteria for the classification and reporting of
osteoarthritis: classification of osteoarthritis of the knee. Diagnostic
and Therapeutic Criteria Committee of the American Rheumatism
Association. Arthritis Rheum 1986;29(8):1039–49.
[26] Belo JN, Berger MY, Koes BW, Bierma-Zeinstra SM. The prog-
nostic value of the clinical ACR classification criteria of knee
osteoarthritis for persisting knee complaints and increase of disabil-
ity in general practice. Osteoarthritis Cartilage 2009;17(10):1288–92,
http://dx.doi.org/10.1016/j.joca.2009.04.002.
[27] Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reli-
ability of the PEDro scale for rating quality of randomised controlled
trials. Phys Ther 2003;83(8):713–21.
[28] Da Costa BR, Hilfiker R, Egger M. PEDro’s bias: summary qual-
ity scores should not be used in meta-analysis. J Clin Epidemiol
2013;66(1):75–7, http://dx.doi.org/10.1016/j.jclinepi.2012.08.003.
[29] Costa LOP, Maher CG, Moseley AM, Elkins MR, Shiwa SR, Her-
bert RD, et al. Da Costa and colleagues’ criticism of PEDro scores
is not supported by the data. J Clin Epidemiol 2013;66(10):1192–3,
http://dx.doi.org/10.1016/j.jclinepi.2013.05.007.
[30] Herbert R, Moseley A, Sherrington C. PEDro: a database of randomised
controlled trials in physiotherapy. Health Inf Manag 1998;28(4):186–8.
[31] Moseley AM, Herbert RD, Maher CG, Sherrington C, Elkins
MR. Reported quality of randomized controlled trials of physio-
therapy interventions has improved over time. J Clin Epidemiol
2011;64(6):594–601, http://dx.doi.org/10.1016/j.jclinepi.2010.08.009.
[32] Armijo-Olivo S, Saltaji H, da Costa BR, Fuentes J, Ha C, Cummings
GG. What is the influence of randomisation sequence generation and
allocation concealment on treatment effects of physical therapy tri-
als? A meta-epidemiological study. BMJ Open 2015;5(9):e008562,
http://dx.doi.org/10.1136/bmjopen-2015-008562.
[33] Savovic J, Weeks L, Sterne JA, Turner L, Altman DG, Moher D,
et al. Evaluation of the Cochrane Collaboration’s tool for assessing
the risk of bias in randomized trials: focus groups, online survey, pro-
posed recommendations and their implementation. Syst Rev 2014;3:37,
http://dx.doi.org/10.1186/2046-4053-3-37.
[34] Atkins D, Eccles M, Flottorp S, Guyatt GH, Henry D, Hill S,
et al. Systems for grading the quality of evidence and the strength
of recommendations I: critical appraisal of existing approaches
The GRADE Working Group. BMC Health Serv Res 2004;4(1):38,
http://dx.doi.org/10.1186/1472-6963-4-38.
[35] Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measur-
ing inconsistency in meta-analyses. BMJ 2003;327(7414):557–60,
http://dx.doi.org/10.1136/bmj.327.7414.557.
[36] Comprehensive meta-analysis version 2.0. [Computer software].
Englewood, NJ: Biostat; 2014.
[37] Cohen J. A power primer. Psychol Bull 1992;112(1):155–9.
[38] Higgins J, S. G. Cochrane handbook for systematic reviews of inter-
ventions.Version 5.1.0. Secondary Cochrane handbook for systematic
reviews of interventions.Version 5.1.0. 2011.
Downloaded for Anonymous User (n/a) at A T Still University from ClinicalKey.com by Elsevier on May 21, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
275
[39] Yang J, Wang HP, Zhou L, Xu CF. Effect of dietary fiber on consti-
pation: a meta analysis. World J Gastroenterol 2012;18(48):7378–83,
http://dx.doi.org/10.3748/wjg.v18.i48.7378.
[40] Weng MC, Lee CL, Chen CH, Hsu JJ, Lee WD, Huang
MH, et al. Effects of different stretching techniques on
the outcomes of isokinetic exercise in patients with knee
osteoarthritis. Kaohsiung J Med Sci 2009;25(6):306–15,
http://dx.doi.org/10.1016/S1607-551X(09)70521-2.
[41] Fitzgerald GK, Fritz JM, Childs JD, Brennan GP, Talisa V, Gil
AB, et al. Exercise, manual therapy, and use of booster sessions
in physical therapy for knee osteoarthritis: a multi-center, factorial
randomised clinical trial. Osteoarthritis Cartilage 2016;24(8):1340–9,
http://dx.doi.org/10.1016/j.joca.2016.03.001.
[42] Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy MG,
Ozturk H, et al. Exercise, education, manual-therapy and taping
compared to education for patellofemoral osteoarthritis: a blinded,
randomised clinical trial. Osteoarthritis Cartilage 2015;23(9):1457–64,
http://dx.doi.org/10.1016/j.joca.2015.04.024.
[43] Cruz-Montecinos C, Flores-Cartes R, Montt-Rodriguez A, Pozo E,
Besoain-Saldana A, Horment-Lara G. Changes in co-contraction during
stair descent after manual therapy protocol in knee osteoarthritis: a pilot,
single-blind, randomized study. J Bodyw Mov Ther 2016;20(4):740–7,
http://dx.doi.org/10.1016/j.jbmt.2016.04.017.
[44] Jardine WM, Gillis C, Rutherford D. The effect of osteopathic manual
therapy on the vascular supply to the lower extremity in individu-
als with knee osteoarthritis: a randomized trial. Int J Osteopath Med
2012;15(4):125–33.
[45] Cheawthamai K, Vongsirinavarat M, Hiengkaew V, Saengrueangrob S.
A comparison of home-based exercise programs with and without self-
manual therapy in individuals with knee osteoarthritis in community. J
Med Assoc Thai 2014;97(Suppl 7):S95–100.
[46] Fish DKH, Brantingham JW, Globe G, Korporaal C, Moen JR. A
randomized clinical trial to determine the effect of combining a top-
ical capsaicin cream and kneejoint mobilisation in the treatment of
osteoarthritis of the knee. ACA News (American Chiropractic Associ-
ation) 2008;4(10):24.
[47] Iudica AC. Can a program of manual physical therapy and supervised
exercise improve the symptoms of osteoarthritis of the knee? J Fam
Pract 2000;49(5):466–7.
[48] Perlman AI, Ali A, Njike VY, Hom D, Davidi A, Gould-
Fogerite S, et al. Massage therapy for osteoarthritis of the knee:
a randomised dose-finding trial. PLoS One 2012;7(2):e30248,
http://dx.doi.org/10.1371/journal.pone.0030248.
[49] Tragord BS, Gill NW, Silvernail JL, Teyhen DS, Allison SC.
Joint mobilization forces and therapist reliability in subjects
with knee osteoarthritis. J Man Manip Ther 2013;21(4):196–206,
http://dx.doi.org/10.1179/2042618613Y.0000000033.
[50] Abbott JH, Chapple CM, Fitzgerald GK, Fritz JM, Childs JD, Har-
combe H, et al. The incremental effects of manual therapy or booster
sessions in addition to exercise therapy for knee osteoarthritis: a ran-
domised clinical trial. J Orthop Sports Phys Ther 2015;45(12):975–83,
http://dx.doi.org/10.2519/jospt.2015.6015.
[51] Courtney CA, Steffen AD, Fernandez-de-Las-Penas C, Kim J, Chmell
SJ. Joint mobilization enhances mechanisms of conditioned pain modu-
lation in individuals with osteoarthritis of the knee. J Orthop Sports Phys
Ther 2016;46(3):168–76, http://dx.doi.org/10.2519/jospt.2016.6259.
[52] Peungsuwan P, Sermcheep P, Harnmontree P, Eungpinichpong W,
Puntumetakul R, Chatchawan U, et al. The effectiveness of Thai
exercise with traditional massage on the pain, walking ability and
QOL of Older people with knee osteoarthritis: a randomized con-
trolled trial in the community. J Phys Ther Sci 2014;26(1):139–44,
http://dx.doi.org/10.1589/jpts.26.139.
[53] Kandada S, Heggannavar A. Effect of Mulligan’s MWM versus Mac-
quarie Injury Management Group (MIMG) protocol on pain and
function in osteoarthritis of knee: a randomised clinical trial. IJTRR
2015;4(4):125–31, http://dx.doi.org/10.5455/ijtrr.00000078.
276 S. Anwer et al. / Physiotherapy 104 (2018) 264–276
[54] Bennell KL, Hinman RS, Metcalf BR, Buchbinder R, McConnell
J, McColl G, et al. Efficacy of physiotherapy management
of knee joint osteoarthritis: a randomised, double blind,
placebo controlled trial. Ann Rheum Dis 2005;64(6):906–12,
http://dx.doi.org/10.1136/ard.2004.026526.
[55] Dwyer L, Parkin-Smith GF, Brantingham JW, Korporaal C, Cassa
TK, Globe G, et al. Manual and manipulative therapy in addi-
tion to rehabilitation for osteoarthritis of the knee: assessor-blind
randomized pilot trial. J Manipulative Physiol Ther 2015;38(1),
http://dx.doi.org/10.1016/j.jmpt.2014.10.002, 1-21.e2.
[56] Nor Azlin MN, Lyn KS. Effects of passive joint mobilization on patients
with knee osteoarthritis. Sains Malays 2011;40(12):1461–5.
[57] Ali SS, Ahmed SI, Khan M, Soomro RR. Comparing the effects of
manual therapy versus electrophysical agents in the management of
knee osteoarthritis. Pak J Pharm Sci 2014;27(4 Suppl):1103–6.
[58] Ko T, Lee S, Lee D. Manual therapy and exercise for OA knee: effects
on muscle strength, proprioception, and functional performance. J Phys
Ther Sci 2009;21(4):293–9.
[59] Godoy VC, Izquierdo TG, Navas IL, Martin DP. Effectiveness of
massage therapy as co-adjuvant treatment to exercise in osteoarthri-
tis of the knee: a randomised control trial. J Back Musculoskelet
2014;27(4):521–9, http://dx.doi.org/10.3233/BMR-140476.
[60] Razek RA, Shenouda MM. Efficacy of Mulligan’s mobilisation with
movement on pain, disability, and range of motion in patients with knee
osteoarthritis: a randomised controlled pilot study. Indian J Physiother
Occup Ther 2014;8(1):242–7.
[61] Pollard H, Ward G, Hoskins W, Hardy K. The effect of a manual therapy
knee protocol on osteoarthritic knee pain: a randomised controlled trial.
J Can Chiropr Assoc 2008;52(4):229–42.
[62] Nam CW, Park SI, Yong MS, Kim YM. Effects of the MWM tech-
nique accompanied by trunk stabilization exercises on pain and physical
dysfunctions caused by degenerative osteoarthritis. J Phys Ther Sci
2013;25(9):1137–40, http://dx.doi.org/10.1589/jpts.25.1137.
[63] Ahmad A, Daud M. A comparative study between joint mobilization
and conventional physiotherapy in knee osteoarthritis. Int J Physiother
2016;3(2):159–62.
[64] Perlman AI, Sabina A, Williams AL, Njike VY, Katz DL.
Massage therapy for osteoarthritis of the knee: a randomised
controlled trial. Arch Intern Med 2006;166(22):2533–8,
http://dx.doi.org/10.1001/archinte.166.22.2533.
[65] Xu Q, Chen B, Wang Y, Wang X, Han D, Ding D, et al. The effectiveness
of manual therapy for relieving pain, stiffness, and dysfunction in knee
osteoarthritis: a systematic review and meta-analysis. Pain Physician
2017;20(4):229–43.
Available online at www.sciencedirect.com
ScienceDirect
Downloaded for Anonymous User (n/a) at A T Still University from ClinicalKey.com by Elsevier on May 21, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
[66] Robertsson O, Wingstrand H, Onnerfalt R. Intracapsular pressure and
pain in coxarthrosis. J Arthroplasty 1995;10(5):632–5.
[67] Lundberg A, Malmgren K, Schomburg ED. Role of joint afferents
in motor control exemplified by effects on reflex pathways from Ib
afferents. J Physiol 1978;284:327–43.
[68] Mangus BC, Hoffman LA, Hoffman MA, Altenburger P. Basic prin-
ciples of extremity joint mobilisation using a Kaltenborn approach. J
Sport Rehabil 2002;11(4):235–50.
[69] Zusman M. Spinal manipulative therapy: review of some proposed
mechanisms, and a new hypothesis. Aust J Physiother 1986;32(2):
89–99, http://dx.doi.org/10.1016/S0004-9514(14)60645-0.
[70] Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ.
The mechanisms of manual therapy in the treatment of muscu-
loskeletal pain: a comprehensive model. Man Ther 2009;14(5):531–8,
http://dx.doi.org/10.1016/j.math.2008.09.001.
[71] NICE (National Institute of Clinical Excellence). The
care and management of osteoarthritis in adults; 2014
www.nice.org.uk/guidance/CG177.
[72] Maitland GD, Hengeveld E, Banks K. Maitland’s peripheral manipu-
lation. 4th ed. Oxford: Butterworth-Heinemann; 2005.
[73] Moss P, Sluka K, Wright A. The initial effects of knee joint mobil-
isation on osteoarthritic hyperalgesia. Man Ther 2007;12(2):109–18,
http://dx.doi.org/10.1016/j.math.2006.02.009.
[74] Takasaki H, Hall T, Jull G. Immediate and short-term
effects of Mulligan’s mobilization with movement on knee
pain and disability associated with knee osteoarthritis—a
prospective case series. Physiother Theory Pract 2013;29(2):
87–95, http://dx.doi.org/10.3109/09593985.2012.702854.
[75] Paungmali A, O’Leary S, Souvlis T, Vicenzino B. Naloxone fails to
antagonize initial hypoalgesic effect of a manual therapy treatment
for lateral epicondylalgia. J Manipulative Physiol Ther 2004;27(3):
180–5, http://dx.doi.org/10.1016/j.jmpt.2003.12.022.
[76] Paungmali A, Vicenzino B, Smith M. Hypoalgesia induced by elbow
manipulation in lateral epicondylalgia does not exhibit tolerance. J Pain
2003;4(8):448–54.
[77] Hall T, Hardt S, Schafer A, Wallin L. Mulligan bent leg
raise technique—a preliminary randomised trial of immediate
effects after a single intervention. Man Ther 2006;11(2):130–5,
http://dx.doi.org/10.1016/j.math.2005.04.009.
[78] Hubbard TJ, Hertel J. Anterior positional fault of the fibula
after sub-acute lateral ankle sprains. Manual Ther 2008;13(1):63–7,
http://dx.doi.org/10.1016/j.math.2006.09.008.
[79] Hubbard TJ, Hertel J, Sherbondy P. Fibular position in individuals
with self-reported chronic ankle instability. J Orthop Sports Phys Ther
2006;36(1):3–9, http://dx.doi.org/10.2519/jospt.2006.36.1.3.